HomeMy WebLinkAboutResolution - 2017-R0477 - Health Reimbursement Arrangement Plan - 12_18_2017Resolution No. 2017-RO477
Item No. 6.16
December 18, 2017
RESOLUTION
BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF LUBBOCK:
THAT the Mayor of the City of Lubbock is hereby authorized and directed to execute for
and on behalf of the City of Lubbock, a Health Reimbursement Arrangement Plan, and related
documents. Said Health Reimbursement Arrangement Plan is attached hereto and incorporated in
this resolution as if fully set forth herein and shall be included in the minutes of the City Council.
Passed by the City Council on December 18, 2017
DANIEL M. POPE, MAYOR
ATTEST:
Rebe ca Garza, City Secr ary
APPROVED, AS TO CONTENT:
Leisa Hutcheson
Director of Human Resources and Risk Management
FORM:
, First Assistant City Attorney
RES.Health Reimbursement Arrangement Plan 2018
12.04.2017
Resolution No. 2017-RO477
HEALTH REIMBURSEMENT ARRANGEMENT
PLAN DOCUMENT
City of Lubbock, Texas
January 1, 2018
TABLE OF CONTENTS
ARTICLE I ADOPTION AGREEMENT.....................................................................1
1.1
Name of Plan: ........................................................................................... 1
1.2
Plan Sponsor.............................................................................................1
1.3
Insurance Committee: .............................................................................. 1
1.4
Effective Date: .......................................................................................... 1
1.5
Eligible Retiree.........................................................................................1
1.6
Benefit Credit: .......................................................................................... 2
1.7
Account......................................................................................................2
1.8
Timing of Credit: ...................................................................................... 2
1.9
Carryover of Accounts.............................................................................2
1.10
Death..........................................................................................................2
ARTICLE II DEFINITION OF TERMS.......................................................................2
2.1
Definitions: ................................................................................................ 2
ARTICLE III PARTICIPATION...................................................................................3
3.1
Agreement to Participation: .................................................................... 3
3.2
Cessation of Participation: ...................................................................... 3
ARTICLE IV FUNDING.................................................................................................4
4.1
Funding: .................................................................................................... 4
ARTICLE V BENEFITS.................................................................................................4
5.1
Provision of Benefits.................................................................................4
5.2
Amount of Reimbursement.....................................................................4
5.3
Expense Reimbursement Procedure.......................................................5
5.4
Carryover of Accounts.............................................................................7
5.5
Death..........................................................................................................7
5.6
ERISA Legal Provisions..........................................................................7
ARTICLE VI
ADMINISTRATION...............................................................................7
6.1
Insurance Committee: .............................................................................. 7
6.2
Duties of the Insurance Committee: ....................................................... 8
6.3
Allocation and Delegation of Duties.......................................................9
6.4
Claims Procedure.....................................................................................9
6.5
Nondiscriminatory Operation: ..............................................................
10
ARTICLEVII HIPAA...................................................................................................10
7.1
Purpose....................................................................................................10
7.2
HIPAA Privacy Compliance..................................................................10
7.3
HIPAA Security Compliance................................................................13
ARTICLE VIII GENERAL PROVISIONS................................................................13
8.1
Amendment and Termination: .............................................................
13
8.2
City Liability...........................................................................................14
8.3
QMCSO:.................................................................................................14
8.4
Facility of Payment.................................................................................14
8.5
Lost Distributees.....................................................................................14
8.6
Status of Benefits....................................................................................14
8.7
Applicable Law.......................................................................................15
8.8
Capitalized Terms..................................................................................15
8.9
Severability.............................................................................................15
ADOPTION......................................................................................................................16
HEALTH REIMBURSEMENT ARRANGEMENT
INTRODUCTION
The City of Lubbock, Texas hereby adopts this Health Reimbursement Arrangement (the
"Plan") for the purpose of allowing certain former employees to obtain reimbursement of
eligible medical expenses incurred by such former employees and their family members. The
City of Lubbock intends the Plan to qualify as a "health reimbursement arrangement" as that
term is defined under IRS Notice 2002-45 and a medical reimbursement plan under Sections
105 and 106 of the Internal Revenue Code of 1986, as amended, and the Plan will be interpreted
at all times in a manner consistent with such intent
ARTICLE I
ADOPTION AGREEMENT
1.1 Name of Plan:
City of Lubbock Health Reimbursement Plan
1.2 Plan Sponsor:
City of Lubbock
Human Resources Director
P.O Box 2000
Lubbock, TX 79457
Telephone Number:(806) 775-2303
Tax Identification Number: 75-6000590
1.3 Insurance Committee:
The Insurance Committee
City of Lubbock
1625 131 Street, Room 104
Lubbock, TX 79401
(806) 775-xxxx
1.4 Effective Date:
January 1, 2018
1.5 Eligible Retiree:
A retiree who is Medicare eligible and enrolled in Medicare Part A and Part B, who is
eligible for a City medical subsidy, and was enrolled in the City's medical plan
immediately prior to retirement and making an irrevocable decision regarding the
continuation of City of Lubbock sponsored Benefits
1.6 Benefit Credit:
i. A Subsidy in an amount equal to $150.00 shall be credited on behalf of each
Participant who is an Eligible Retiree.
a. ii. A Subsidy in an amount equal to $150.00 shall be credited on
behalf of each Participant who is an Eligible Spouse or Surviving
Spouse of an Eligible Retiree
1.7 Account:
One HRA Account will be established per Participant.
1.8 Timing of Credit:
Benefit Credit specified in Section 1.6 will be credited to HRA Accounts on the
first day of each calendar month.
1.9 Carryover of Accounts:
Credits remaining in an HRA Account (after the expiration of the claims run -out
period) at the end of a Plan Year shall be carried over to the following Plan Year to
reimburse Participants for Health Care Expenses incurred during subsequent Plan
Years.
1.10 Death:
Surviving Spouse of retiree will continue to receive the credit until his/her death.
ARTICLE II
DEFINITION OF TERMS
2.1 Definitions:
Whenever used in this Plan, the following terms shall have the meanings set forth
below.
i. "HRA Account" means the account established for a Participant to hold his
or her Benefit Credits.
i `Benefit Credit" means the amount credited to a Participant's HRA Account
for the provision of benefits under the Plan.
i "COBRA" means the Consolidated Omnibus Budget Reconciliation Act of
1985, as amended.
iv. "Code" means the Internal Revenue Code of 1986, as amended.
V. "City" means the City of Lubbock.
vi. "ERISA" means the Employee Retirement Income Security Act of 1974, as
amended.
\t "Health Care Expense" means an expense incurred by a Participant or by a
Participant's Spouse for medical care as defined in Code Section 213(d) and
the rules, regulations and Internal Revenue Service interpretations, including
2
premiums for health care insurance coverage, or other eligible expenses
approved by the City. Health Care Expenses shall not include expenses
reimbursed or reimbursable under any private, employer -provided, or public
health care reimbursement or insurance arrangement or any amount claimed
as a deduction on the federal income tax return of the Participant or the
Participant's Spouse. Health Care Expenses are incurred when the medical
care is provided, not when the Participant is formally billed, charged for, or
pays the expenses.
A. "HIPAA" means the Health Insurance Portability and Accountability Act of
1996, as amended.
uc. "Participant" a person who participates in this Plan as specified under Section
3.1
x "Plan" means this plan, The City of Lubbock Health Reimbursement Plan
named in Section 1.1 and set forth herein, as may be amended.
A "Plan Year" means, with respect to the initial Plan Year, the period from the
Effective Date through the next following December 31. Thereafter, "Plan
Year" means the twelve (12)-month period commencing on each January 1.
A. "PHI" means protected health information as described in 45 C.F.R.
§ 164.103, and generally includes individually identifiable health information
held by or on behalf of the Plan.
A "Spouse" means the husband or wife of an Eligible Retiree from the City.
)dv. "Third Party Administrator" means Connecture and its subcontractors, or
subsequently appointed administrator appointed by the City.
ARTICLE III
PARTICIPATION
3.1 Agreement to Participate:
To participate, an Eligible Retiree (or Eligible Retiree's Spouse, as the case may be)
must have:
i. become eligible for coverage under Subchapter XVIII of Chapter 7 of Title
42 of the United States Code (Medicare); and
ii. timely and fully completed enrollment forms made available by the City for
that purpose
3.2 Cessation of Participation:
An Eligible Retiree shall cease to be a Participant on the earliest of the following to
apply to the Eligible Retiree, and an Eligible Retiree's Spouse shall cease to be a
Participant on the earliest of the following to apply to the Spouse:
i. Death
ii. As to the Spouse, termination of the marriage
3
iii. With respect to an Eligible Dependent, the date he or she ceases to be eligible
for coverage under Subchapter XVIII of Chapter 7 of Title 42 of the United
States Code (Medicare):
iv. Termination of this Plan with respect to an Eligible Dependent Spouse, the
date he or she divorces the Eligible Retiree;
v. with respect to an Eligible Retiree, the date he or she is rehired as an active
benefit eligible employee of the City;
vi. the effective date of any Plan amendment that renders him or her ineligible to
participate;
vii. the effective date of request for opt -out by the Eligible Retiree or Eligible
Dependent Spouse; or
viii. the termination of the Plan.
Reimbursement from the Participant's HRA Account after termination of participation
shall be governed by Section 5.2.
ARTICLE IV
FUNDING
4.1 Funding:
i. In no event may any benefits under the Plan be funded with Participant
contributions.
ii. The HRA Account balance does not accrue interest at anytime.
ARTICLE V
BENEFITS
5.1 Provision of Benefits:
The Plan will reimburse Participants for, or pay on a Participant's behalf, Health Care
Expenses, up to the balance in the Participant's HRA Account. A Participant shall be
entitled to reimbursement/payment under this Plan only for Health Care Expenses
incurred after he or she becomes a Participant in the Plan and before his or her
participation has ceased. In no event shall any benefits under this Plan be provided in
the form of cash or any other taxable or nontaxable benefit other than
reimbursement/payment for Health Care Expenses.
5.2 Amount of Reimbursement:
At all times during the Plan Year, a Participant shall be entitled to benefits under this
Plan for payment of Health Care Expenses in an amount that does not exceed the
balance of his or her HRA Account. Each reimbursement or payment made hereunder
shall be a charge to such HRA Account available to pay Health Care Expenses under
the Plan.
4
5.3 Expense Reimbursement/Payment Procedures:
A. Reimbursement for Health Care Expenses shall be made in accordance with this
Section 5.3.
Tinting: Reimbursement shall only be permitted by written application to the
Third Party Administrator for eligible Health Care Expense incurred during
Participation. The Participant may submit claims for reimbursement for
Health Care Expenses incurred prior to his or her loss of eligibility,
provided the Participant files such claims within one hundred eighty (180)
days of such loss of eligibility.
Claims Substantiation: The Insurance Committee shall require the
Participant to furnish a bill, receipt, cancelled check, or other written
evidence or certification of payment or of obligation to pay Health Care
Expenses. The Insurance Committee reserves the right to verify to its
satisfaction all claimed Health Care Expenses prior to reimbursement.
Unless otherwise permitted by the Third Party Administrator, each request
for reimbursement shall include the following information:
a. The amount of the Health Care Expense for which
reimbursement is requested;
b. The date the Health Care Expense was incurred;
C. A brief description and the purpose of the Health Care
Expense;
d. The name of the person for whom the Health Care Expense
was incurred and, if such person is not the Participant
requesting reimbursement, the relationship of the person to
such Participant;
e. The name of the person, organization or other provider to
whom the Health Care Expense was or is to be paid;
f. A statement that the Participant has not been and will not be
reimbursed for the Health Care Expense by insurance or
otherwise, and has not been allowed a deduction in a prior year
(and will not claim a tax deduction) for such Health Care
Expense under Code Section 213; AND
g. A written bill from an independent third party stating that the
Health Care Expense has been incurred and the amount of
such expense and, at the discretion of the Insurance
Committee, a receipt showing payment has been made.
Expenses eligible for coverage under any medical, HMO, prescription, dental, or
vision care plans in which the Participant is enrolled must be submitted first to all
appropriate claims administrators for such plans before submitting the expenses to
the Provider for reimbursement under the Plan. A Participant who is entitled to
payment or reimbursement under a health care reimbursement account in a cafeteria
plan under Code Section 125 must receive his or her maximum annual
reimbursement under the health care reimbursement account in the cafeteria plan
before he or she is entitled to any reimbursement under this Plan.
i Decision by Insurance Como:ittee: The Third Party Administrator shall
review such claim and respond within thirty (30) days after receiving the
claim. If the Third Party Administrator determines that an extension is
necessary due to matters beyond the control of the Plan, the Provider will
notify the claimant within the initial thirty (30)-day period that the
Provider needs up to an additional fifteen (15) days to review the claim. If
such an extension is necessary because the claimant failed to provide the
information necessary to evaluate the claim, the notice of extension will
describe the information that the claimant will need to provide to the
Provider. The claimant will have no less than forty-five (45) days from the
date he or she receives the notice to provide the requested information. The
Provider shall provide to every claimant who is denied a claim for benefits
(in whole or in part) written or electronic notice setting forth in a manner
calculated to be understood by the claimant:
a. The specific reason or reasons for the denial;
b. Specific reference to pertinent plan provisions on which denial
is based;
c. A description of any additional material or information
necessary for the claimant to perfect the claim and an
explanation of why such material or information is necessary;
d. A copy of any internal rule, guideline, protocol, or other
similar criterion relied upon in making the initial
determination or a statement that such a rule, guideline,
protocol, or other criterion was relied upon in making the
appeal determination and that a copy of such rule will be
provided to claimant free of charge upon request; and
e. A description of the Plan's appeal procedures.
i Rights to Appeal: Claims that are partially or wholly denied may be appealed
to the Insurance Committee as provided in Section 6.4.
B. Direct payment to providers for Health Care Expenses shall be made in accordance
with this Section 5.3
Payment for certain eligible expenses for, or related to, goods and/or
services received directly by the Participant from an approved Provider may
be paid electronically from a Participant's HRA Account through the use of
a debit type card issued to the Participant by the Administrator. Payment
shall be made in accordance with agreement(s) between the City and the
C.
Administrator, and may be subject to review.
ii. Lost or stolen cards should be immediately reported to the Administrator.
Administrator may charge a nominal fee to Participant for a replacement
card(s).
iii. City nor Administrator assume liability for transactions not approved due
to insufficient funds in the Participant's HRA Account.
iv. Rights to Appeal: Payments that are partially or wholly denied may be
appealed to the Insurance Committee as provided in Section 6.4.
5.4 Carryover of Accounts:
To the extent a Participant has a balance in his or her HRA Account at the end of a
Plan Year, the balance shall be carried over to following Plan Years to the extent
elected by the Plan Sponsor in Section 1.9.
5.5 Death:
In the event the Plan Sponsor elects a combined account structure in Section 1.7, and
the Eligible Retiree dies without a spouse who is a Participant, his or her HRA Account
shall be forfeited; provided, however, that his or her estate or representatives may
submit claims for Health Care Expenses incurred by the Eligible Retiree prior to the
Eligible Retiree's death, as long as such claims are submitted no later than one -
hundred eighty (180) days after the Eligible Retiree's death.
5.6 ERISA Legal Provisions:
i The Plan may not restrict benefits for any hospital length of stay in connection
with childbirth for the mother or newborn child to less than forty-eight (48)
hours following a normal vaginal delivery, or less than ninety-six (96) hours
following a cesarean section, or require that a provider obtain authorization
from the Plan or the insurance issuer for prescribing a length of stay not in
excess of the above periods.
To the extent the Plan provides benefits with respect to mastectomy, it will
provide, in the case of an individual who is receiving benefits in connection
with a mastectomy and who elects reconstruction in connection with such
mastectomy, coverage for all stages of reconstruction of the breast on which
a mastectomy was performed, surgery and reconstruction of the other breast
to provide a symmetrical appearance, prostheses, and coverage of physical
complications at all stages of the mastectomy, including lymphedemas.
ARTICLE VI
ADMINISTRATION
6.1 Insurance Committee:
The Insurance Committee is responsible for the performance of all reporting and
disclosure obligations required to be performed by the Insurance Committee under the
7
Code. The Insurance Committee shall be the designated agent for service of legal
process with respect to the Plan.
6.2 Duties of the Insurance Committee:
The Insurance Committee shall have the sole discretion and authority to control and
manage the operation and administration of the Plan.
i The Insurance Committee shall have complete discretion to interpret the
provisions of the Plan, make findings of fact, correct errors, supply
omissions, and determine the benefits payable under this Plan. All decisions
and interpretations of the Insurance Committee made in good faith pursuant
to the Plan shall be final, conclusive and binding on all persons, subject only
to the claims procedure, and may not be overturned unless found by a court
to be arbitrary and capricious.
i The Insurance Committee shall have all other powers necessary or desirable
to administer the Plan, including, but not limited to, the following:
a. To prescribe procedures to be followed by Participants in
making elections under the Plan and in filing claims under the
Plan;
b. To prepare and distribute information explaining the Plan to
Participants;
c. To receive from Participants such information as shall be
necessary for the proper administration of the Plan;
d. To keep records of elections, claims, and disbursements for
claims under the Plan, and any other information as
appropriate;
e. To appoint individuals or committees to assist in the
administration of the Plan and to engage any other agents,
including a Third Party Administrator as he/she deems
advisable;
f. To accept, modify or reject Participant elections under the
Plan;
g. To promulgate election forms and claims forms to be used by
Participants, which may be electronic in nature;
h. To correct errors and make equitable adjustments for mistakes
made in the administration of the Plan, specifically, and
without limitation, to recover erroneous overpayments made
by the Plan to a Participant or Dependent, in whatever manner
the Insurance Committee deems appropriate, including
suspensions or recoupment of, or offsets against, future
payments due that Participant or Dependent.
E]
6.3 Allocation and Delegation of Duties:
The Insurance Committee shall not be liable for any acts or omissions of such
employee, officer, member, or to any others to whom duties have been delegated.
6.4 Claims Procedure:
i Within one hundred and eighty (180) days of receipt by a claimant of a notice
under Section 5.3 denying a claim in whole or in part, the claimant or his or
her duly authorized representative may request in writing a full and fair
review of the claim by the Insurance Committee. In connection with such
review, the claimant or his or her duly authorized representative may, upon
request and free of charge, have reasonable access to, and copies of, all
documents, records and other information relevant to the claim for benefits,
and may submit issues and comments in writing. The Insurance Committee
shall make a decision promptly, but not later than sixty (60) days after the
receipt of a request for review. The decision on review shall be in writing,
in a manner calculated to be understood by the claimant, and shall include:
a. Specific reasons for the decision;
b. Specific references to the pertinent plan provisions on which
the decision is based;
c. A statement that the claimant is entitled to receive, upon
request and free of charge, reasonable access to, and copies of,
all documents, records, and other information relevant to the
claim for benefits;
d. A copy of any internal rule, guideline, protocol, or other
similar criterion relied upon in making the initial
determination or a statement that such a rule, guideline,
protocol, or other criterion was relied upon in making the
appeal determination and that a copy of such rule will be
provided to claimant free of charge upon request; and
i The decision of the Insurance Committee shall be final and conclusive on all
persons claiming benefits under the Plan, subject to applicable law. If
claimant challenges the decision of the Insurance Committee within one
year after the date of the decision, a review by a court of law will be limited
to the facts, evidence and issues presented during the claims procedure set
forth above. The appeal process described herein must be exhausted before
a claimant can pursue the claim in a court of competent jurisdiction. Facts
and evidence that become known after having exhausted the appeals
procedure may be submitted for reconsideration of the appeal in accordance
with the time limits established above. Issues not raised during the appeal
will be deemed waived.
9
6.5 Nondiscriminatory Operation:
All rules, decisions, interpretations and designations by the Insurance Committee
under the Plan shall be made in a nondiscriminatory manner, and persons similarly
situated shall be treated alike.
ARTICLE VII
HIPAA
7.1 Purpose:
This Article permits the Plan to disclose PHI to the Plan Sponsor to the extent that
such PHI is necessary for the Plan Sponsor to carry out its administrative functions
related to the Plan. This Article reflects the requirements set forth in 45 C.F.R. §
164.504(f) of HIPAA and the related regulations promulgated by the U.S.
Department of Health and Human Services. Any term used in this Article VII shall
have the meaning set forth in HIPAA and guidance issued thereunder.
7.2 HIPAA Privacy Compliance:
i. Disclosures to Plan Sponsor: In accordance with HIPAA, the Plan may
disclose summary health information to the Plan Sponsor as requested by
the Plan Sponsor to allow it to modify, amend or terminate the Plan, or
obtain premium bids from insurers to provide health insurance coverage
under the Plan. The Plan may disclose to the Plan Sponsor information on
whether an individual is participating or enrolled in the Plan. In addition,
the Plan may disclose protected health information to the Plan Sponsor as
necessary to allow the Plan Sponsor to perform plan administration
functions, as used within the meaning of the HIPAA privacy regulations,
including the following functions:
a. Collection of individual premiums or contributions;
b. Conducting quality assessment and improvement activities,
population -based activities relating to improving health or
reducing health care costs, protocol development, case
management and care coordination, contacting of health care
providers and patients with information about treatment
alternatives, and related functions;
c. Reviewing health plan performance;
d. Activities relating to obtaining or renewing health insurance
or determining premium pricing for such benefits, or placing
a contract for reinsurance of risk relating to such claims;
e. Conducting or arranging for medical review, legal services,
and auditing functions, including fraud and abuse detection
and compliance programs;
f. Business planning and development of the Plan, such as
conducting cost -management and planning -related analyses,
including formulary development and administration,
10
development or improvement of methods of payment
or coverage policies;
g. Business management and general administrative activities of
the Plan;
h. Determination of eligibility or coverage (including
coordination of benefits or the determination of cost sharing
amounts), and adjudication or subrogation of benefit claims;
i. Billing, claims management, collection activities, obtaining
payment under a stop -loss contract, and related health care
data processing;
j. Review of health care services with respect to medical
necessity, coverage under a health plan, appropriateness of
care or justification of charges;
k. Utilization review activities;
I. Disclosure to consumer reporting agencies of any of the
following protected health information relating to collection
of premiums or reimbursement:
• Name and address;
• Date of birth;
• Social security number;
Payment history;
• Account number;
• Name and address of the health care provider
and/or health plan; and
m. Risk adjusting amounts due to enrollee health status and
demographic characteristics.
ii. Access to Medical Information: The following employees or individuals
under the control of the Plan Sponsor shall have access to the Plan's
protected health information to be used solely for the purposes described
above:
a. Insurance Committee
b. Such other classes of individuals identified by the Plan's
Privacy Officer as necessary for the Plan's administration.
iii. Insurance Committee and Privacy Officer Agreement to Restrictions: The
Plan will not disclose protected health information to the Insurance
Committee and Privacy Officer until the Plan Sponsor has certified to the
Plan that it agrees to:
a. Not use or disclose protected health information other than as
permitted or required by law or as specified above;
11
b. Not use or disclose the protected health information in any
employment -related decisions or in connection with any other
benefit or employee benefit plan;
c. Report to the Plan any use or disclosure of protected health
information that is inconsistent with the uses and disclosures
permitted by law or specified above of which City becomes
aware;
d. Make protected health information accessible to the subject
individual in accordance with 45 CFR
§ 164.524;
e. Allow the subject individuals to amend or correct their
protected health information in accordance with 45 CFR §
164.526;
f. Make available the information to provide an accounting of its
disclosures of protected health information in accordance with
45 CFR § 164.528;
g. Make its internal practices, books and records available to the
Secretary of Health and Human Services for determining
compliance;
h. Return or destroy the protected health information received, if
feasible, after it is no longer needed for the original purpose
and retain no copies of such information or if not feasible,
restrict access and uses as required by 45 CFR
§ 164.504(f)(2)(ii)(I);
L Ensure that any agents, including a subcontractor, of the Plan
Sponsor to whom the Plan Sponsor provides protected health
information shall also agree to these same restrictions;
j. Restrict access to protected health information to those classes
of employees or individuals identified above; and
k. Restrict the use of protected health information by those
employees identified above for plan administration functions
within the meaning at 45 CFR § 164.504(a).
iv. Noncompliance Resolution: If there is noncompliance with the above
restrictions by a designated employee or other individual receiving
protected health information on behalf of the Plan Sponsor, the employee
or other individual shall be subject to appropriate discipline in accordance
with the City's disciplinary procedures. Complaints or issues of
noncompliance by such persons shall be filed with the Plan's Privacy
Official.
12
7.3 HIPAA Security Compliance:
i. Insurance Committee Obligations: The Insurance Committee shall do the
following:
a. Implement administrative, physical, and technical safeguards
that reasonably and appropriately protect the confidentiality,
integrity, and availability of the electronic PHI that it creates,
receives, maintains, or transmits on behalf of the Plan;
b. Ensure that the adequate separation required by 45 CFR §
164.504(f)(2)(iii) is supported by reasonable and appropriate
security measures;
C. Ensure that any agent, including a subcontractor, to whom it
provides electronic PHI agrees to implement reasonable and
appropriate security measures to protect the information;
d. Report to the Plan any security incident of which it becomes
aware;
e. Make the Plan Sponsor's internal practices, books, and records
relating to security of electronic PHI received from the Plan
available to the Secretary of Health and Human Services (or
any other officer or employee of the U.S. Department of
Health and Human Services to whom the authority involved
has been delegated) for purposes of determining compliance
by the Plan with the HIPAA security standards.
Exclusions: The provisions of (a) apply to all disclosures of electronic PHI
by the Plan to the Insurance Committee except:
a. Disclosures of summary health information to the Plan
Sponsor as reasonably requested by the Plan Sponsor to allow
it to modify, amend or terminate the Plan, or to obtain
premium bids from insurers to provide health insurance
coverage under the Plan;
b. Disclosures of information on whether an individual is
participating or enrolled in the Plan; and Disclosures of
information authorized by an individual in accordance with 45
CFR § 164.508.
ARTICLE VIII
GENERAL PROVISIONS
8.1 Amendment and Termination:
Although the City intends to maintain the Plan for an indefinite period, the City
reserves the right to amend, modify, or terminate this Plan at any time, including but
not limited to the right to modify eligibility for participation, benefits paid by the
13
Plan, and the right to reduce or eliminate existing HRA Accounts. Notwithstanding
anything to the contrary contained in this Section 8.1 or elsewhere in the Plan, the
Insurance Committee shall have the authority to approve all technical, administrative,
regulatory and compliance amendments to the Plan, and any other amendments that
will not increase the cost of the Plan to the City, as the Insurance Committee shall
deem necessary or appropriate.
8.2 City Liability:
Benefits under the Plan are paid by the City out of their general assets. Specifically,
and notwithstanding anything herein to the contrary, the City who employs the
Participant as of the date of the Participant's qualifying retirement shall be solely
responsible for the payment of benefits to such Participant and his or her family
members under this Plan. The City shall have no liability with respect to the
payment of any benefits hereunder to any Participant last employed by any other
Company prior to eligibility under the Plan or his or her family members.
8.3 QMCSO:
In the event the Insurance Committee receives a medical child support order (within
the meaning of ERISA Section 609(a)(2)(B)), the Insurance Committee shall notify
the affected Participant and any alternate recipient identified in the order of the
receipt of the order and the Plan's procedures for determining whether such an order
is a qualified medical child support order (within the meaning of ERISA Section
609(a)(2)(A)).
Within a reasonable period, the Insurance Committee shall determine whether the
order is a qualified medical child support order and shall notify the Participant and
alternate recipient of such determination.
8.4 Facility of Payment:
If the Insurance Committee deems any person incapable of receiving benefits to
which he or she is entitled by reason of minority, illness, infirmity, or other
incapacity, it may direct that payment be made directly for the benefit of such person
or to any person selected by the Insurance Committee to disburse it. Such payments
shall, to the extent thereof, discharge all liability of the Insurance Committee, Plan
Sponsor and the City.
8.5 Lost Distributees:
Any benefit shall be deemed forfeited if, after reasonable efforts, the Insurance
Committee is uable to locate the Participant to whom payment is due.
8.6 Status of Benefits:
Neither the City nor the Insurance Committee makes any commitment or guarantee
that any amounts paid to or for the benefit of a Participant under this Plan will be
excludable from the Participant's gross income for federal, state, or local income tax
purposes. It shall be the obligation of each Participant to determine whether each
payment under this Plan is excludable from the Participant's gross income for
14
federal, state, and local income tax purposes and to notify the Insurance Committee
or City if the Participant has any reason to believe that such payment is not so
excludable. Any Participant, by accepting a benefit under this Plan, agrees to be
liable for any tax that may be imposed with respect to those benefits, plus any
interest as may be imposed.
8.7 Applicable Law:
The Plan shall be construed and enforced according to the laws of the state of State
of Texas, to the extent not preempted by any Federal law.
8.8 Capitalized Terms:
Capitalized terms shall have the meaning set forth in Article II.
8.9 Severability:
If any provision of this Plan shall be held invalid or unenforceable, such invalidity
or unenforceability shall not affect any other provision, and this Plan shall be
construed and enforced as if such provision had not been included.
IN WITNESS WHEREOF, we have executed this Plan Document the date
and year first written above.
ATTEST:
City
TO CONTENT:
City of L bbock
BY:
TITLE: Daniel M. Pope, Mayor
Leisa Hutcheson, Director of Human Resources
AED S T M:
hM cell iAs i ant City Attorney
15
ADOPTION AGREEMENT
FOR THE
CONNECTURE AND CITY OF LUBBOCK
HEALTH REIMBURSEMENT ARRANGEMENT
The undersigned Employer adopts CONNECTURE Health Reimbursement Arrangement and elects the
following provisions:
EMPLOYER AND PLAN INFORMATION
EMPLOYER'S NAME, ADDRESS AND TELEPHONE NUMBER
Name: City of Lubbock
Address: 1625 13th Street, Room 104
Street
Lubbock TX 79401
City State Zip
Telephone: 806-775-2 317
2. EMPLOYER'S TAXPAYER IDENTIFICATION NUMBER: 75-6000590
ERISA PLAN NAME: City of Lubbock Health Reimbursement Arrangement
4. EFFECTIVE DATE
a. ✓ The Health Reimbursement Arrangement is anew plan effective as of January 1,
2018
b. ❑ The Health Reimbursement Arrangement is an amendment and restatement of an
existing plan. The effective date of the amendment and restatement is
1. ❑ The HRA is a Grandfathered Plan that was in effect on March 23, 2010.
2. ✓ The HRA is not a Grandfathered Plan.
5. ERISA PLAN NUMBER
a. ❑ 501
b. ✓ Other:503
6. PLAN ADMINISTRATOR
a. ✓ Employer (Use Employer name, address and telephone number).
b. ❑ Use name, address and telephone number below:
Name: City of Lubbock
Address: P.O. Box 2000
Street
Lubbock TX 79457
City State Zip
Telephone: 806-775-2317
Page 1 of 6
ADOPTION AGREEMENT
FOR THE
CONNECTURE AND CITY OF LUBBOCK
HEALTH REIMBURSEMENT ARRANGEMENT
7. AFFILIATED EMPLOYERS
The following Affiliated Employers (i.e., entities within the Employer's controlled group) will adopt
this Health Reimbursement Arrangement as Participating Employers:
a. ✓ N/A
b. ❑ Name of Affiliated Employer(s):
8. PLAN YEAR
The Plan Year shall end on:
a. ✓ December 31
b. ❑ The last day of the month of
ELIGIBILITY REQUIREMENTS
9. ELIGIBLE EMPLOYEES
a. ❑ All employees are eligible — no exclusions.
b. ❑ All employees are eligible except for the following (select all that apply):
1. ❑ Union employees
2. ❑ Non-resident aliens
3. ❑ Leased employees
4. ❑ Part-time employees scheduled to work less than hours per week.
5. ❑ Employees who are not eligible for the Employer's major medical coverage.
6. ❑ Other:
C. PLAN IS FOR MEDICARE ELIGIBLE RETIREES AND MEDICARE
ELIGIBLE DEPENDENTS ONLY
10. WAITING PERIOD
Any Eligible Employee will be eligible to participate in the Health Reimbursement Arrangement
upon satisfaction of the following waiting period:
a. ❑ Date of hire or attainment of Eligible Employee status (no waiting period)
b. ❑ Same waiting period as Employer's major medical coverage
c. ❑ months after date of hire
d. ❑ days after date of hire
e. ✓ Other: Medicare eligible retirees and Medicare eligible dependents are eligible the first
of the month upon attainment of age 65: must be enrolled in Medicare A and B.
Page 2 of 6
ADOPTION AGREEMENT
FOR THE
CONNECTURE AND CITY OF LUBBOCK
HEALTH REIMBURSEMENT ARRANGEMENT
11. EFFECTIVE DATE OF PARTICIPATION
An Eligible Employee who has satisfied the eligibility and waiting period requirements of Items 9
and 10 will become a Participant on:
a. ✓ the day on which such requirements are satisfied.
b. ✓ the first day of the month coinciding with or next following the date on which such
requirements are satisfied.
c. ❑ the first day of the calendar quarter coinciding with or next following the date on which
such requirements are satisfied.
d. ❑ the first day of the pay period coinciding with or next following the date on which such
requirements are satisfied.
e. ❑ the same day as the Employer's major medical coverage.
f. ✓ Other: Medicare eligible retirees and Medicare eligible dependents are eligible the first of the month
upon attainment of age 65: must be enrolled in Medicare A and B.
12. DEPENDENTS
The HRA will cover the following dependents (select all that apply):
a. ✓ Spouses for Federal income tax purposes; any eligible spouse covered under the City's
Health Plan upon attainment of age 65.
b. ❑ Children
1. ❑ [Required if is selected and PPACA applies l Biological children, adopted
children, stepchildren and eligible foster children who have not attained the age
of 26.
2. ❑ Children for whom the Employee is a legal guardian.
3. ❑ Other children who are Federal tax dependents of the Employee.
c. ❑ Any other individuals who are Federal tax dependents of the Employee.
BENEFITS
13. HRA CONTRIBUTIONS
The Employer will contribute to each Participant's HRA Account the following amount based on
the frequency selected:
a. ✓ $ 150 per month
b. ❑ $ per quarter
c. ❑ $ per plan year
d. ❑ Other
14. QUALIFYING MEDICAL EXPENSES
The following expenses will be considered as Qualifying Medical Expenses under the HRA:
a. ✓ All medical expenses under IRC 213(d), as modified by IRC 105(b).
b. ❑ All medical expenses under IRC 213(d), excluding insurance premiums.
c. ❑ All medical expenses under IRC 213(d), excluding mileage.
d. ❑ Only expenses that qualify for a limited purpose HRA (dental, vision and preventive care).
e. ❑ Only expenses that qualify for a limited purpose HRA (dental and vision only, not subject
to PPACA).
f. ❑ The following types of expenses only (select all that apply):
Page 3 of 6
ADOPTION AGREEMENT
FOR THE
CONNECTURE AND CITY OF LUBBOCK
HEALTH REIMBURSEMENT ARRANGEMENT
1. ❑ Health insurance premiums only (not subject to PPACA).
2. ❑ Health insurance premiums and dental and vision expenses only (not subject to
PPACA).
3. ❑ Only co -payments, deductibles and co-insurance under the Employer's major
medical coverage.
4. ✓ Other: Premiums, expenses not covered by Medicare Parts A and B. RX
copayments and RX expenses not covered by Medicare Part D "donut hole", wigs for
medicine induced hair loss
15. HEALTH FLEXIBLE SPENDING ARRANGEMENT
If the Employer maintains a health flexible spending arrangement, claims will be processed in the
following order:
a. ✓ Not applicable — no health FSA.
b. ❑ Health FSA expenses will be processed first.
c. ❑ HRA expenses will be processed first.
16. CLAIMS FOR REIMBURSEMENT MUST BE FILED WITHIN
a. ✓ 180 days following each plan year
AND,
For Participants who terminate employment, will a different filing deadline apply?
b. ❑ Yes, days following termination of employment
c. ❑ No
17. CARRY FORWARD
Amounts not used by the end of a Plan Year shall:
a. ✓ Carry forward to the next Plan Year.
b. ❑ Carry forward to the next Plan Year, subject to the following limitations or restrictions:
c. ❑ Shall forfeit as of the end of the Plan Year
18. SPEND DOWN
After HRA eligibility terminates (e.g., termination of employment, retirement):
a. ✓ Any unused amounts in an HRA Account will forfeit.
b. ✓ Any unused amounts in an HRA Account will continue to be eligible for reimbursement for
180 days.
c. ❑ Any unused amounts in an HRA Account will continue to be eligible for reimbursement for
retirees.
d. ❑ Any unused amounts in an HRA Account will continue to be eligible for reimbursement for
those Employees who satisfy the following conditions
, and for all other Employees
unused amounts shall forfeit once HRA eligibility terminates.
APPLICATION OF OTHER LAWS
19. FAMILY AND MEDICAL LEAVE ACT
FMLA generally applies to Employers who have 50 or more employees in the preceding or
current calendar year. (The Employer is required to inform CONNECTURE if this provision
changes for any future calendar year.)
Page 4 of 6
ADOPTION AGREEMENT
FOR THE
CONNECTURE AND CITY OF LUBBOCK
HEALTH REIMBURSEMENT ARRANGEMENT
a. ❑ FMLA applies.
b. ✓ FMLA does not apply.
20_ COBRA
COBRA generally applies to Employers who have 20 or more employees in the preceding
calendar year. (The Employer is required to inform CONNECTURE if this provision changes for
any future calendar year.)
a. ❑ COBRA applies.
a. ✓ COBRA does not apply.
Page 5 of 6
ADOPTION AGREEMENT
FOR THE
CONNECTURE AND CITY OF LUBBOCK
HEALTH REIMBURSEMENT ARRANGEMENT
This Adoption Agreement may be used only in conjunction with the CONNECTURE AND CITY OF
LUBBOCK Master and Prototype Health Reimbursement Arrangement. This Adoption Agreement and
the CONNECTURE AND CITYOF LUBBOCK Master and Prototype Health Reimbursement Arrangement
shall together be known as the Health Reimbursement Arrangement or HRA.
City of Lubbock
Name of Employer
By:
Printed Name: W. Jarrett Atkinson
Title: City Manager `
Signature Date: / ?-
Page 6 of 6